Pressure Sores - Clinical Practice and Scientific Approach

288 Pages·1990·26.588 MB·English

by  Dan L. Bader (eds.)

Pressure Sores - Clinical Practice and Scientific
Approach
To my daughter Laetitia
PRESSURE SORES
Clinical Practice and
Scientific Approach
Edited by
DanL. Bader
Department of Materials
Queen Mary College, University of London
M
MACMILLAN
PRESS
Scientific & Medical
© The editor and contributors 1990
Softcover reprint of the hardcover 1st edition 1990 978-0-333-46178-5
All rights reserved. No reproduction, copy or transmission of
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Any person who does any unauthorised act in relation to this
publication may be liable to criminal prosecution and civil
claims for damages.
First published 1990 by
THE MACMILLAN PRESS LTD
Houndmills, Basingstoke, Hampshire RG21 2XS
and London
Companies and representatives
throughout the world
ISBN 978-1-349-10130-6 ISBN 978-1-349-10128-3 (eBook)
DOI 10.1007/978-1-349-10128-3
A catalogue record for this book is available
from the British Library.
Reprinted 1992
Contents
Foreword Robert B. Duthie ix
Preface xi
The Contributors xiii
PART I CLINICAL ASPECTS OF PRESSURE SORES
1 The Importance of Pressure Sores in Total Health Care
James Robertson, Ian Swain and Ian Caywood 3
Introduction - An Overview 3
Pressure Sores and the Concept of Tissue Viability 6
Tissue Viability Parameters 9
Pressure Sores and Wound Healing-Patient Support Systems 10
Wound Care 11
Managerial Aspects of Sores 12
The Tissue Viability Society 12
2 Pathogenesis of Pressure Sores
J. T. Scales 15
Introduction 15
Structure and Function of Human Skin 16
Causation of Pressure or Distortion Sores 19
3 Pressure Sores: Clinical Aspects of Their Cost, Causation and
Prevention
Brian Livesley 27
An Expensive Epidemic 27
Practical Management and Presdisposing Medical Conditions 28
Factors Predisposing to Pressure Sores 31
Relieving Pressure 32
4 The Economics of Pressure Sore Prevention
Pam Hibbs 35
The Cost of Pressure Sores 35
The Cost of a Prevention Plan for a Health District 39
Education 41
5 Current Management for the Prevention of Pressures Sores
Rosemary A. Crow and Michael Clark 43
vi Contents
Introduction 43
Identifying the Risk of Developing Pressure Sores 43
Selecting Treatment to Prevent Pressure Sores 46
Monitoring the Patient's Progress 49
Strategy to Ensure Good Practice 49
PART II EXPERIENCES IN VARIOUS CLINICAL DISCIPLINES
6 Orthopaedics
Christopher Bulstrode 55
Introduction 55
Present Attitudes 55
Incidence 55
Causation 57
7 Geriatric Medicine
M. Bliss 65
Incidence 65
Aetiology 65
Pathology 66
Prognosis 69
Prevention 69
Healing Pressure Sores 75
8 The Severely Disabled
George Cochrane 81
Definition 81
Diseases and Disorders in which Risks are High 81
Prophylaxis 87
Treatment of an Established Pressure Sore 92
9 Spinal Injury
J. R. Silver 97
Historical Background 97
Pathogenesis 99
The Long-term Effects of Pressure Sores 109
10 Reconstructive Surgery
Christopher Khoo and Bruce N. Bailey 117
Introduction 117
General Plan of Treatment 117
The Problem of Recurrence 118
The Development of Reconstructive Surgery 119
Principles of Flap Design 121
Contents vii
Surgical Management 125
Pressure Sores in Specific Sites 128
Post-operative Management 137
PART III SCIENTIFIC ASPECTS OF PRESSURE SORES
11 Cellular Responses to Tissue Distortion
Terence J. Ryan 141
Introduction 141
Cellular Responses to Mechanical Forces 142
Tissue Organisation and the Transmission of Mechanical
Forces 145
How are Biochemical Signals Induced by Mechanical Forces? 146
12 Microvascular Mechanisms in Stasis and Ischaemia
C. C. Michel and Hilary Gillott 153
Introduction 153
Reactive Hyperaemia 154
The Veni-Arteriolar Response 157
Partial Arterial Occlusion and Venous Congestion 158
Microvascular Responses to Tissue Compression 159
Reperfusion Failure and Reperfusion Injury 160
13 The Metabolic Basis of Wound Healing
A. W. Goode 165
Introduction 165
Biochemical Components of Healing 165
The Phases of Healing 167
The Measurement of Wound Healing 171
14 Biomechanics of Tissue Distortion and Stiffness by Magnetic
Resonance Imaging
Steven I. Reger, Thomas F. McGovern and Kao Chi Chung 177
Introduction 177
Methods 177
Results 178
Conclusions 189
15 Effects of Compressive Loading Regimens on Tissue Viability
DanL. Bader 191
Introduction 191
Effects of Prolonged Loading 193
Effects of Repeated Loading 195
Discussion 197
viii Contents
16 Effects of Mechanical Stresses on Lymph and Interstitial Fluid
Flows
Narender P. Reddy 203
Introduction 203
Physiology of the Lymphatic System 206
Effects of Mechanical Stresses on Regional Lymph Flow 213
Effects of Mechanical Stresses on Interstitial Fluid Flux 215
PART IV TECHNOLOGICAL SYSTEMS FOR PATIENT
MONITORING
17 Ischial Pressure Distribution Under the Seated Person
Dan L. Bader and M. B. Hawken 223
Introduction 223
The Performance of Selected Support Cushions 225
Discussion 231
18 Pressure Management and the Recumbent Person
Thomas A. Krouskop, Susan L. Garber and Philip Noble 235
Introduction 235
Limitations of Biomechanical Studies of Tissue Breakdown 235
General Medical Condition 237
Considerations in Selecting Support Surfaces 239
Patient Diagnosis and Lifestyle Considerations 246
19 Movement Studies During Sleep
J. C. Barbenel 249
Introduction 249
Techniques for the Measurement of Movements in Bed 250
Movement Patterns 254
Mobility and Pressure Sore Risk 256
20 Remote Monitoring of Wheelchair Sitting Behaviour
Martin W. Ferguson-Pel/, Debra E. Hurwitz, Thomas G.
Burn and R. Masiello 261
Introduction 261
Design Considerations 263
Performance of Monitoring System 267
Discussion 271
Index 275
Foreword
Robert B. Duthie, CBE, MA, ChM, FRCS
This is a first. This textbook deals with one of the major scourges of
mankind, namely the pressure sore.
All aspects-whether in the physical and mental suffering of the involved
individual, or in the economics, or in the understanding of the basic
phenomena behind the lesion, or in its causation, recognition of presenta
tion and improved treatment modalities - are examined critically and
commented upon authoritatively by many experts.
Five per cent of all hospital inpatients, i.e. 30 000 per year, have
developed a pressure sore either just before, during or after admission.
There are probably even greater numbers in the community.
Twenty-one variables are described which can now be recognised to
identify, with a 98 per cent accuracy, those at risk. All health care staff
must be taught to distinguish as many of these variables as possible, for
example general and systemic conditions of the patient, local conditions of
malnutrition, blood supply, abnormal pressures and lack of ability to shift
pressures when required. Once these factors have been discerned, steps
should be taken to prevent or improve them.
In addition there are several excellent scientific chapters describing
known sensors of measurement, techniques of nursing, positioning and
splinting.
However, the field of pathophysiology behind the pressure sore is
extraordinary complex and diverse and this too has been brought out
clearly by several authors.
An excellent chapter for nurses is included which should however also be
required reading for all medical students, housemen and indeed consul
tants. With such a galaxy of authors, including clinicians, epidemiologists
and scientists, there must always be some overlap in data and in expres
sion. But this is a multi-disciplinary subject, each discipline with its own
language, stretching from a list of homeopathy lotions to the hard science
of measuring tissue oxygen levels - for such measurements in absolute
terms are required to delineate when cell necrosis occurs at the various
anatomical sites.
The fashion of medicine, with all its financial support, rushes on and
leaves in its wake the hard core of clinical conditions, e.g. pain, fractures
and pressure sores, all producing long-drawn-out and chronic morbidities.
This book brings a new look at the field of pressure sores, and highlights
lX